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					    Student Name        ____________________________________________________________________________________
                                             (Last)                                   (First)                                   (Middle Initial)

    Date of Birth       __________________             Male        Female           Social Security Number ______________________
                            Month/Day/Year

    Local Address       ________________________________________________________ Phone (______)______________
                                   (Number & Street)                        (City)               (Zip)

    Home Address        ________________________________________________________ Phone (______)______________
                                   (Number & Street)                        (City)               (Zip)




    Parent(s) Name ____________________________________________________________________________________
                                             (Last)                                   (First)                                   (Middle Initial)

    Home Address        ________________________________________________________ Phone (______)______________
                                   (Number & Street)                        (City)               (Zip)




    Are you covered by group or individual health and/or accident insurance?                     Yes                No 
      If yes, please provide the following information:

    Insurance Co.       ___________________________________________________ Policy #_________________________

    Subscriber's Name ________________________________________                        Subscriber's Soc.Sec. #______________________




    Name _______________________________________ Phone (______)____________ Relationship ________________

    Name _______________________________________ Phone (______)____________ Relationship ________________




    Name      _______________________________________________________________ Phone (_______)____________



    Please check ALL appropriate boxes for the sports in which you will be participating at this college:
         Baseball            Field Hockey          Hockey                 Soccer                   Track
         Basketball          Football              Rowing                 Softball                 Volleyball
         Cross Country       Golf                  Skating                Swimming                 Wrestling
         Diving              Gymnastics            Skiing                 Tennis                   Other __________

                           PLEASE CAREFULLY AND COMPLETELY READ THE FOLLOWING INFORMATION

            Completion of this medical history and examination form is mandatory for participation in the sports programs of this college. Please make
sure that all statements regarding your personal information and medical history is complete and accurate.
            NWAACC Regulations state: After July 1st and prior to the first practice of each year of participation in intercollegiate athletics at a member
college, a student-athlete shall undergo a medical examination and be approved for intercollegiate athletic competition by a medical authority licensed to
perform a physical examination by the laws applicable in the state where the exam is conducted. Those licensed and approved to perform physical
examinations include Medical Doctors (M.D.), Doctors of Osteopathy (D.O.), Certified Registered Nurses (C.R.N.), Naturopaths (N.D.) and Physician's
Assistants (P.A.).
            This form is to be completed and signed by the student or, if the student is under the age of 18, by the student's parent or guardian. Any
Information withheld or falsified may affect the student's status on the athletic team and/or the student's scholarship funding. The college reserves the
right, with the student's authorization, to request past medical records, charts and diagnoses regarding injuries, medical history or physical condition,
and may request additional medical examinations or tests if indicated.
NWAACC (2004)                                                                                                                            Page 1 of 6
YOUR LAST PHYSICAL EXAMINATION

Date ___________________               Doctor's name __________________________________                City, State __________________

Please list any abnormalities found on any past physical examinations _________________________________________________
_________________________________________________________________________________________________________

IMMUNIZATION RECORD
       Measles*                 Yes              No              Date of last shot     __________________
       Mumps*                   Yes              No              Date of last shot     __________________
       Rubella*                 Yes              No              Date of last shot     __________________
       Polio                    Yes              No              Date of last dose     __________________
       Tetanus (Td)             Yes              No              Date of last shot     __________________

           *Note: These are commonly noted on immunization records as "MMR" and often given as one shot.
                  A second dose of measles vaccine is recommended for college entrance.

FAMILY MEDICAL HISTORY
       Please check YES or NO in appropriate box.
  1.      Yes          No        Osteoporosis                             5.    Yes         No         Hemophilia
  2.      Yes          No        High blood pressure                      6.    Yes         No         Diabetes
  3.      Yes          No        Neuromuscular disease                    7.    Yes         No         Anemia
  4.      Yes          No        Sudden death from heart                  8.    Yes         No         Cancer
                                   disease or stroke
      If living, please check box to signify family member's general health. If deceased, please state age and cause of death, if known.
                                                                                                   Age at Death     Cause of Death
Father            Excellent        Good          Fair          Poor           Deceased        ______________________________
Mother            Excellent        Good          Fair          Poor           Deceased        ______________________________
Brother #1        Excellent        Good          Fair          Poor           Deceased        ______________________________
Brother #2        Excellent        Good          Fair          Poor           Deceased        ______________________________
Sister #1         Excellent        Good          Fair          Poor           Deceased        ______________________________
Sister #2         Excellent        Good          Fair          Poor           Deceased        ______________________________

MEDICAL CONDITIONS & ILLNESSES
      Have you ever had or do you now have any of the following medical conditions, illnesses or diseases?
      Please check YES or NO for EACH item.
         YES      NO                                    YES     NO                                          YES     NO
 9.                    Polio                   26.                 Recurrent sinusitis           43.                 Hernia or rupture
10.                    Diphtheria              27.                 Hearing loss/ear disease      44.                 Ulcers
11.                    Rheumatic fever         28.                 Rheumatic heart disease       45.                 Testicular masses
12.                    Hepatitis               29.                 Heart murmur/problems         46.                 Hemorrhoids
13.                    Tuberculosis            30.                 Pericarditis                  47.                 Bleeding disease
14.                    Collapsed lung          31.                 High blood pressure           48.                 Anemia
15.                    Pneumonia               32.                 Elevated cholesterol          49.                 Phlebitis
16.                    Pleurisy                33.                 Arthritis/joint problems      50.                 Asthma/hay fever
17.                    Diabetes                34.                 Bone infection                51.                 Skin disease/rash
18.                    Allergies               35.                 Chondromalacia                52.                 Measles
19.                    Tumors/Cancer           36.                 Seizures/Epilepsy             53.                 Mumps
20.                    Muscular disease        37.                 Migraine headaches            54.                 Mononucleosis
21.                    Eye disease             38.                 Neurological disorder         55.                 Malaria
22.                    Color blindness         39.                 Goiter/thyroid disease        56.                 Car or air sickness
23.                    Near sightedness        40.                 Enlarged organs (spleen)      57.                 Nervous breakdown
24.                    Far sightedness         41.                 Kidney or bladder disease     58.                 Mental disorder
25.                    Nasal polyps            42.                 Gastrointestinal bleeding     59.                 Eating disorder


Student Name ________________________________________________________                                                    Page 2 of 6
                 (Last)          (First)          (Mid. Initial)
INJURIES & SYMPTOMS

      Do currently have or have you ever had any of the following symptoms, problems or injuries?
      Please check YES or NO for EACH item.
         YES        NO                                        YES        NO                                               YES       NO
60.                       Frequent headache          71.                    Neck pain or injury               82.                     Muscle weakness
61.                       Head injury                72.                    Back pain or injury               83.                     Muscle cramps
62.                       Visual changes             73.                    Knee pain or injury               84.                     Muscle wasting
63.                       Eye pain or injury         74.                    Ankle pain or injury              85.                     Frequent nausea
64.                       Ringing in ears            75.                    Shoulder dislocation/sep.         86.                     Frequent vomiting
65.                       Sore throats               76.                    Other joint sprain/disloc.        87.                     Frequent diarrhea
66.                       Nasal fracture             77.                    Joint pain, at rest               88.                     Abdominal problems
67.                       Sinus congestion           78.                    Joint pain, with exercise         89.                     Internal injuries
68.                       Breathing difficulty       79.                    Joint weakness                    90.                     Rectal bleeding
69.                       Recurrent coughing         80.                    Pinched nerve                     91.                     Unusual fatigue
70.                       Chest pain                 81.                    Heat exhaustion/stoke             92.                     Trouble sleeping

GENERAL QUESTIONS
       Please answer ALL of the following questions by checking either YES or NO for EACH item.
           YES       NO
 93.                       Do you now have or have you ever had any chronic or recurrent illnesses?
 94.                       Have you ever had any illnesses lasting more than one week?
 95.                       If no to #93 or #94, do you now have or have you ever had any illnesses requiring treatment and care of a doctor?
 96.                       Do you wear eyeglasses or contact lenses?
 97.                       Do you currently wear eyeglasses or contact lenses while participating in sports?
 98.                       Do you use any dental appliances such as braces, bridges or plates?
 99.                       Any body parts or organs missing (appendix, eye, kidney, testicles)?
100.                       Are you now or have you ever been under the treatment of a medical doctor for any injuries?
101.                       Have you ever fainted, passed out, been dizzy, knocked out, unconscious or had a concussion?
102.                       Have you ever had a cast, splint, cane or crutches?
103.                       Have you ever had an X-ray of any bone or joint?
104.                       Do you have to stop while running twice around a quarter-mile track?
105.                       Do you have any trouble breathing, while at rest, after running one mile?
106.                       Do you get any chest pain with exercise?
107.                       Have you ever had any injuries or illnesses that caused you to miss a game or practice?
108.                       Are there any reasons why you should not participate in sports?
109.                       Have any of your close relatives, under the age of 50, died of heart problems or unexplained causes?
110.                       Are you or any member of your family allergic to ANY medications (aspirin, penicillin, etc.)?
111.                       Are you now taking or have you taken any medications, medicines, drugs or vitamins on a regular basis?
112.                       Do you have any medical conditions that require special attention or treatment that the coach or athletic trainer should be
                             aware of in the event of any injury or illness?

If you have answered "Yes" to any numbered item (1-112), please explain the situation or circumstances, including names of treating
physicians and dates in the space provided. Identify each response by the number of the item in the left margin.
Item No.       Physician, City, State              Approx. Date     Explanation, including any surgeries you have had




Student Name ________________________________________________________                                                                 Page 3 of 6
                 (Last)          (First)          (Mid. Initial)
Please list all previous fractures, concussions or other head injuries:
Item No.     Physician, City, State               Approx. Date       Injury




Please list all hospitalizations:
Item No.     Physician, City, State               Approx. Date       Reason for hospitalization, length of stay




Describe your current pattern of physical exercise
Activity                                Frequency                                Duration                             Intensity




Describe the sickest you have ever been __________________________________________________________________________

___________________________________________________________________________________________________________

Describe any weight changes over the last six months________________________________________________________________

List all medications -- prescription and/or over the counter -- drugs or vitamins that you currently take (including aspirin, birth control
pills, etc.) ___________________________________________________________________________________________________

___________________________________________________________________________________________________________

Describe any allergies -- from bites, drugs, foods, pollen, etc. -- you may have, including causes and reactions ___________________

___________________________________________________________________________________________________________

At what age did you have your first menstrual period? ______                        How many have you had during the last 12 months? _______

Date of last period ________              Describe any menstrual irregularity or discomfort _______________________________________

AGREEMENT OF UNDERSTANDING
           I, the undersigned, certify that the above medical history is correct and true to the best of my knowledge, and that this student has no physical
defects except as stated. This medical information is given with my permission and the medical examination is taken voluntarily. I further understand
that any intentional omission of answers either verbally or in writing may result in disqualification from the community college sports program.
           I authorize the release of this medical information, including the medical examination and the results of any medical tests, to the college for
their use, evaluation and record keeping for this student-athlete's participation in the sports program of the college. I further authorize the release of this
medical information, the medical examination and the results of any medical tests when deemed necessary by the college athletic coach, athletic trainer
or other authorized college official; and I grant permission to any hospital, physician, surgeon, or other duly authorized medical personnel to release any
other medical records, charts or diagnoses when deemed necessary for the treatment and care of this student-athlete in the event of injury or illness.
           I further authorize and request the college's designated medical personnel to administer basic life support, advanced life support, and/or to
obtain emergency medical care in the event of injury or illness at any specific emergency care facility so designated by the college physician or
representative while participating in the sports program.
           By my signature I verify that I have read, understand and agree to the above-stated conditions.

Student _______________________________________________________________                                  Date ___________________________

Parent/Guardian (If student is under 18 years of age)______________________________________________________________________


Student Name ________________________________________________________                                                                    Page 4 of 6
                 (Last)          (First)          (Mid. Initial)
PHYSICAL EXAMINATION FOR SPORTS PARTICIPATION
To be completed by Licensed Medical Provider


To the Medical Provider: Please obtain and review the student's health history, pages one through four of this form, before conducting
the examination. The intent of this exam is to focus on conditions of the athlete that may endanger his/her health, aggravate pre-
existing conditions or increase the risk of death from participation in competitive college sports. If your findings or observations during
this exam for sports participation indicate a need for a more comprehensive medical examination, you have the option of conducting a
more comprehensive exam or advising the athletic director of the college in writing of the need for same. We appreciate your
assistance and cooperation in maintaining the health of our student-athletes.
Student Name      ____________________________________________________________________________________
                                       (Last)                              (First)                               (Middle Initial)

Date of Birth     __________________            Male       Female        Height ___________            Weight ___________
                      Month/Day/Year

Blood pressure at rest and sitting:    Left arm _________/_________ mmHG                      Right arm _________/_________ mmHG
Resting pulse rate:         Apical __________              Radial __________
Visual acuity: Left 20/________        Right 20/________       Please check appropriate box:  With correction       Without correction
Please check appropriate box to indicate if Normal or Abnormal, and provide comments if abnormal.
        SYSTEM                                                               N       AB                       COMMENTS
HEAD                        Hair, scalp, masses, injuries
EYES                        Proptosis, conjunctivae, sclera, EOM,
                            pupillary size, reaction to light,
                            peripheral vision, fundi, gross tension to
                            palpation
EARS                        Gross hearing to speech, drums,
                            discharges
NOSE                        Septum, mucosa, sinuses
THROAT/MOUTH                Teeth, tongue, tonsils, infections, lesions
NECK                        Thyroid, vessels, range of motion,
                            adenopathy, masses, voice
                            abnormalities
THORAX/LUNGS                Shape, expansion, deformities, rhonchi,
                            wheezes, rales
HEART                       PMI, sounds, thrills, murmurs, gallops,
                            PVCs
LYMPHATICS                  Cervical, axillary
ABDOMEN                     Organ enlargement (liver, spleen, etc.),
                            masses, tenderness, hernias, scars
GENITALIA                   Scrotum, testicles, lesions, discharge,
                            hernias
RECTAL (Optional)           Hemorrhoids, fissures, prostate, masses
UPPER EXTREMITIES           Range of motion, joint stability, muscle
                            strength, limitations, effusion,
                            ecchymoses, atrophy, deformities,
                            edema, clubbing, pulses, veins, injuries
LOWER EXTREMITIES           Range of motion, joint stability, muscle
                            strength, limitations, effusion,
                            ecchymoses, atrophy, deformities,
                            edema, clubbing, pulses, veins, injuries
BACK                        Flexion, extension, scoliosis, kyphosis,
                            excessive lordosis, injuries
NEUROLOGICAL                Cranial nerves, reflexes, motor, gait,
                            balance, sensory
SKIN                        Texture, striae, rash, acne
MENTAL STATUS               Affect, hostility, agitation

                                                                                                                            Page 5 of 6
LABORATORY TESTS (Optional or as indicated by examination)


Urinalysis:       Sugar _________       Albumin _________   Keytones _________       Other _________________________________

Hematology:       Hematocrit ________________________

Summary of abnormal lab work __________________________________________________________________________________

If medical history indicates the need for any vaccinations or booster shots, please administer during the physical
examination.
Orthopedic Diagnoses ________________________________________________________________________________________

___________________________________________________________________________________________________________


General Medical Diagnoses ____________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Additional findings or comments on health history/significant injuries or illnesses ___________________________________________

___________________________________________________________________________________________________________

DISPOSITION (Please check one)
          Unrestricted activity in all sports

          No participation until ______________ or until ____________________________________________________________
                                        (Date)                                 (Conditions to be met)

          May participate, but with following limitations _____________________________________________________________

          May not participate at all for following reasons ____________________________________________________________


Medical Provider's signature _____________________________________________               Date of Exam _______________________


MEDICAL PROVIDER IDENTIFICATION                        (Please print. Stamp or label okay)

Name ____________________________________________________________                   Phone (______) _________________________

Address __________________________________________________________                  City ____________________ Zip ___________


Mail completed form to:




NOTE: The original of this report shall be confidentially filed and maintained in the athletic department. The information
shall be readily available to health care providers in event of an emergency when intercollegiate sports are conducted,
both at home and away from the college.


Student Name ________________________________________________________                                          Page 6 of 6
                         (Last)           (First)         (Mid. Initial

				
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